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AbdominalAorticAneurysm
KeyFeatures
EssentialsofDiagnosis

Mostaorticaneurysmsareasymptomaticuntilrupture,whichiscatastrophic
Aneurysmsmeasuring5cmarepalpablein80%ofpatients
Backorabdominalpainwithaneurysmaltendernessmayprecederupture
Hypotension
Excruciatingabdominalpainthatradiatestotheback
GeneralConsiderations

Theaortaofahealthyyoungmanmeasuresapproximately2cm
Ananeurysmisconsideredpresentwhentheaorticdiameterexceeds3cm
Aneurysmsrarelycauseruptureuntildiameterexceeds5cm
90%ofabdominalatheroscleroticaneurysmsoriginatebelowtherenalarteries
Aorticbifurcationisusuallyinvolved
Commoniliacarteriesareofteninvolved
Demographics

Foundin2%ofmenoverage55
Maletofemaleratiois4:1

ClinicalFindings
SymptomsandSigns

MostasymptomaticaneurysmsarediscoveredasincidentalfindingsonultrasoundorCTimaging
Symptomaticaneurysms
Mildtoseveremidabdominalpainduetoaneurysmalexpansionoftenradiatestolowerback
Painmaybeconstantorintermittent,exacerbatedbyevengentlepressureonaneurysmsack,andmay
alsoaccompanyinflammatoryaneurysms
Inflammatoryaneurysmshaveaninflammatorypeel,similartotheinflammationseenwithretroperitoneal
fibrosis,surroundstheaneurysmandencasesadjacentretroperitonealstructures,suchastheduodenum
and,occasionally,theureters
Rupturedaneurysms
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Severepain
Palpableabdominalmass
Hypotension
Freeruptureintotheperitonealcavityislethal
Mostaneurysmshaveathicklayerofthrombusliningtheaneursymalsac
Embolizationtolowerextremitiesisrarelyseen
DifferentialDiagnosis

Diagnosis
LaboratoryTests

Hematocritwillbenormal,sincetherehasbeennoopportunityforhemodilution
Patientswithaneurysmsmayalsohavethecardiopulmonarydiseasesofelderlymalesmokers,whichinclude
Coronaryarterydisease
Carotiddisease
Renalimpairment
Emphysema
Preoperativetestingmayindicatethepresenceofthesecomorbidconditions
ImagingStudies

Abdominalultrasonography
Diagnosticstudyofchoiceforinitialscreening
Usefulinscreening65to74yearoldmen,butnotwomen,whohaveahistoryofsmoking
Repeatedscreeningdoesnotappeartobeneeded
Abdominalorbackradiographs:curvilinearcalcificationsoutliningportionsofaneurysmwallmaybeseenin
approximately75%ofpatients
CTscans
Provideamorereliableassessmentofaneurysmdiameter
Shouldbedonewhentheaneurysmnearsthediameterthreshold(5.5cm)fortreatment
ContrastenhancedCTscans
Showthearteriesaboveandbelowtheaneurysm
Visualizationofthisvasculatureisessentialforplanningrepair

Treatment
EmergencyRepair
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Ifthebleedingisconfinedtotheretroperitoneum,bloodlossmaybearrestedlongenoughforthepatientto
undergourgentoperation
Endovascularrepairisavailableforurgentaneurysmrepairinmostmajorvascularcenters,withtheresults
offeringsomeimprovementoveropenrepairforthesecriticallyillpatients
ElectiveRepair

Generallyindicatedforaorticaneurysms5.5cmindiameteroraneurysmsthathaveundergonerapid
expansion(>.5cmin6months)
Surgery

Notindicatedwheninflammatoryaneurysmispresentunlessretroperitonealstructures,suchastheureter,
arecompressed
Interestingly,theinflammationthatencasesaninflammatoryaneurysmrecedesaftereitherendovascularor
opensurgicalaneurysmalrepair
Opensurgicalaneurysmrepair
Graftissuturedtothenondilatedvesselsaboveandbelowtheaneurysm
Thisinvolvesanabdominalincision,extensivedissection,andinterruptionofaorticbloodflow
Mortalityrateislow(25%)whentheprocedureisperformedingoodriskpatientsinexperiencedcenters
Older,sickerpatientsmaynottoleratecardiopulmonarystressesofthesurgery
EndovascularRepair

Stentgraftisusedtolinetheaortaandexcludetheaneurysm
Anatomicrequirementstosecurelyachieveaneurysmexclusionvaryaccordingtoperformance
characteristicsofthespecificstentgraftdevice
Stentmustbeabletosealsecurelyagainstthewalloftheaortaaboveandbelowtheaneurysm,thereby
excludingbloodfromflowingintotheaneurysmsac
Longtermsurvivalisequivalentbetweenthetwotechniques
Patientswhoundergoendovascularrepairrequiremorerepeatinterventionsandneedtobemonitored
postoperativelysincethereisa1015%incidenceofcontinuedaneurysmgrowthpostendovascularrepair

Outcome
FollowUp

Onceananeurysmisidentified,routinefollowupwithultrasounddeterminessizeandgrowthrate
Thefrequencyofimagingdependsonaneurysmsizerangingfromevery2yearsforsmall(<4cm
aneurysms)toevery6monthsforaneurysmsatorapproaching5cm
Atapproximately5cm,aCTangiographywithcontrastshouldbedonetomoreaccuratelysizetheaneurysm
anddefinetheanatomy
Complications
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Myocardialinfarction
Routineinfrarenalaneurysms
Respiratorycomplicationsaresimilartothoseseeninmostmajorabdominalsurgery
Gastrointestinalhemorrhage
Prognosis

Openelectivesurgicalresection
Mortalityrateis15%
Ofthosewhosurvivesurgery,about60%arealiveat5years
Myocardialinfarctionisleadingcauseofdeath
Endovascularaneurysmrepair
Maybelessdefinitivethanopensurgicalrepair
Inhighriskpatients,endovascularapproachreducesperioperativemorbidityandmortality
Prognosisdependsonhowsuccessfullyaneurysmhasbeenexcludedfromthecirculation
Mortalityratesamongpatientswithlargeaneurysms
12%annualriskofruptureinaneurysms6cmindiameter
25%annualriskofruptureinaneurysms7cmdiameter
WhentoRefer

Anypatientwitha4cmaorticaneurysmorlargershouldbereferredforimagingandassessmentbya
vascularspecialist
Urgentreferralsshouldbemadeifthepatientcomplainsofpainandgentlepalpationoftheaneurysm
confirmsthatitisthesource,regardlessofaneurysmsize
WhentoAdmit

Signsofaorticrupture

References
DeBruinJLetal.Longtermoutcomeofopenorendovascularrepairofabdominalaorticaneurysm.NEnglJ
Med.2010May20362(20):18819.
[PubMed:20484396]
JacksonRSetal.Comparisonoflongtermsurvivalafteropenvsendovascularrepairofintactabdominalaortic
aneurysmamongMedicarebeneficiaries.JAMA.2012Apr18307(15):16218.
[PubMed:22511690]
KimLGMulticentreAneurysmScreeningGroup.etal.Asustainedmortalitybenefitfromscreeningfor
abdominalaorticaneurysm.AnnInternMed.2007May15146(10):699706.
[PubMed:17502630]
KurosawaKetal.Currentstatusofmedicaltreatmentforabdominalaorticaneurysm.CircJ.2013Nov25
77(12):28606.
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[PubMed:24161907]
LederleFAOpenVersusEndovascularRepair(OVER)VeteransAffairsCooperativeStudyGroup.etal.
Outcomesfollowingendovascularvsopenrepairofabdominalaorticaneurysm:arandomizedtrial.JAMA.2009
Oct14302(14):153542.
[PubMed:19826022]
SchermerhornMLetal.Endovascularvs.openrepairofabdominalaorticaneurysmsintheMedicare
population.NEnglJMed.2008Jan31358(5):46474.
[PubMed:18234751]
UnitedKingdomEVARTrialInvestigatorsGreenhalghRMetal.Endovascularversusopenrepairofabdominal
aorticaneurysm.NEnglJMed.2010May20362(20):186371.
[PubMed:20382983]
WallaceGAetal.Favorabledischargedispositionandsurvivalaftersuccessfulendovascularrepairofruptured
abdominalaorticaneurysm.JVascSurg.2013Jun57(6):1495502.
[PubMed:23719035]

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